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  • PHSO: Unlocking Solutions in Imaging: working together to learn from failings in the NHS (8 July 2021)

    • UK
    • Reports and articles
    • Pre-existing
    • Public domain
    • No
    • Parliamentary and Health Service Ombudsman
    • 08/07/21
    • Health and care staff, Patient safety leads

    Summary

    This report shares findings from complaints made to Parliamentary and Health Service Ombudsman (PHSO) about failings in imaging in the NHS. The majority of these complaints involve people who had cancer at the time they used imaging services.

    Through highlighting these complaints, the PHSO’s objective is to support NHS services to improve. It suggests that failings in imaging services can only be addressed and learned from through collaboration across clinical specialties, looking at the whole imaging journey and its intersections as part of the patient’s care pathway.

    Content

    Findings

    The PHSO analysed 25 complaints relating to failings in the imaging journey since 2013. Most concluded between 2018 and 2020. This report focuses on four key findings they have seen in their casework

    1. Failure to follow national guidelines on reporting unexpected imaging findings.
    2. Failure to act on important unexpected findings.
    3. Delays in reporting imaging findings.
    4. Failure to learn from past mistakes.

    Recommendations

    For the system as a whole:

    • Recommendations from previous work related to imaging must be implemented as a priority (referring to previous reports by the Healthcare Safety Investigation Branch, Care Quality Commission and the Independent Review of Diagnostic Services).
    • Digital infrastructure must now be treated as a patient safety issue.
    • Department of Health and Social Care and NHS England and NHS Improvement should ensure there is national guidance on the roles and responsibilities of clinicians, and expected timeframes, at each stage of the imaging journey.
    • Department of Health and Social Care and NHS England and NHS Improvement should write to the Health and Social Care Select Committee and the Public Administration and Constitutional Affairs Committee by the end of March 2022.

    For imaging services specifically:

    • All NHS-funded providers that have a radiology service should ensure staff working in those services have sufficient allocated time in their job plans for meaningful learning and reflection.
    • Clinical directors and senior managers of NHS-funded radiology services should triangulate the learning from across their departments on a regular basis.
    • The Royal College of Radiologists should review existing guidance on reporting unexpected findings and peer review of radiological reports to learn from the findings of PHSO’s casework.
    PHSO: Unlocking Solutions in Imaging: working together to learn from failings in the NHS (8 July 2021) https://www.ombudsman.org.uk/publications/unlocking-solutions-imaging-working-together-learn-failings-nhs
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